Philadelphia is in the midst of a debate about whether it should encourage comprehensive user engagement sites or CUES — commonly known as “safe-injection sites” or “safe-consumption sites” — to open. Opponents found their voice in Pennsylvania Attorney General Josh Shapiro.
I have the utmost respect for Shapiro, but his statements are ill-informed and misleading. Enough is enough.
Three times wrong
There are three main components to Shapiro’s opposition. The first is that there are only “some studies” that show the benefits of CUES. Shapiro says, “I don’t think there’s clear evidence.” The second argument is that, because heroin and fentanyl are so dangerous, using is “like playing Russian roulette … You have no idea whether you’re going to live or whether you’re going to die.”
The first argument is wrong. The second argument is one of the main reasons to support CUES. The evidence for the benefits of CUES has been demonstrated multiple times. Literally every study that evaluated those sites found that they fulfill their objectives. Even data from an underground site in the U.S. shows positive results. While Shapiro is right about how dangerous injection-drug use is, he ignores the fact that, from a treatment perspective, an opioid overdose is a very simple condition. Naloxone, also known by its generic name of Narcan, is a life-saving drug that reverses opioid-related overdoses in a matter of seconds. Getting people to use in a site that has naloxone, as does every CUES, makes injecting drugs like a game of Russian roulette with a gun with no bullets. It is telling that not a single person has died of overdose in nearly 100 sites around the world.
The third and final component in Shapiro’s opposition to CUES is more complicated. It is about the law. “Changes in state and federal law would need to occur for these sites to operate legally.” This is neither fully accurate, nor is it a reason for opposition.
The legality of CUES is arguable under the current law. There are two sections of the federal Controlled Substances Act that one could point to in opposition: the prohibition of drug possession and the “crack house statute.” However, legal scholars argue that “there are reasonable arguments for the proposition that the law should not be read to cover a [safe-injection facility]” as the law “was never intended to interfere with legally authorized public health interventions.”
Federal prohibition aside, there are two facts that Shapiro ignores: Not all laws are enforced, and laws can be changed.
Syringe-exchange success can be informative
The history of the legality of syringe-exchange programs seems to be forgotten. In the early 1990s, in the midst of the HIV epidemic, most states had laws that criminalized the possession and distribution of drug paraphernalia. Despite this, 11 cities and 10 states changed their laws to allow for syringe-exchange programs by 1996. Philadelphia was among those cities after Mayor Ed Rendell signed an executive order authorizing a “citywide sterile syringe-exchange program” in 1992. By the mid-’90s, at least nine syringe-exchange programs also operated with no clear legal basis.
Massachusetts, New Jersey, and California tried to go after syringe-exchange workers. Out of a total of 11 completed prosecutions between 1990-1995, only two cases ended in convictions. Most acquittals were through a necessity defense — the syringe-exchange worker convinced the jury that “his or her actions were reasonably intended to avert greater harm.”
By 2017, 19 states and the District of Columbia explicitly authorized syringe-exchange programs. In other states, such as Pennsylvania, although syringe-exchange programs are not authorized explicitly by law, they are are also not banned.
Law must be adapted to respond to the needs of society. When syringe-exchange programs were first suggested, the arguments in opposition were very similar to the arguments we hear today: They would increase crime, enable drug use, and not save lives. Thanks to legal pioneering, courageous providers, understanding juries, and some law enforcement agencies turning a blind eye to allow syringe exchanges to operate, we now have the evidence that led the Centers for Disease Control and Prevention to recommend opening more syringe-exchange programs.
We would be wise to learn from this experience when we think about how to move ahead with CUES.
CUES are an evidence-based practice that will save lives at a time when drugs are more potent and cheaper than ever. We can either argue about the legality of sites under current law or take active steps to ensure a legal basis for their operation. It would be great if the top legal official in our state would join us on this journey.